Cancer deaths in the U.S. alone were over 500,000 in 2001, and in spite of many advances, cancer remains one of the leading killers (1). There is a critical need for the development of new anti-cancer agents, especially those with novel and selective mechanisms of action. Although some of the promise of non-cytotoxic therapies is beginning to be realized (e.g. immunostimulants, growth factor antagonists, anti-sense therapy), the mainstay of the treatment of most cancers remains with cytotoxic drugs. In view of the limited success rates, incidence of toxicities, and development of resistance to such agents, there is a dire need for new classes of these drugs, especially those that may act by new mechanisms or exhibit exploitable selectivity. There is also a need for a better understanding of dosing, scheduling, and concomitant therapies in order to optimize treatment protocols.
Natural products have historically been a rich source of new, successful prototype classes of lead compounds from which analogs have been developed. According to a recent review, 60% of the anti-infective and anti-cancer drugs that have successfully advanced to the clinic are derived from natural products (2). Examples of these among currently used anti-cancer agents include the anthracycline class (e.g., doxorubicin), the Catharanthus (Vinca) alkaloids, paclitaxel, and derivatives of podophyllotoxin and camptothecin. A recently published tabulation of natural product-based anti-tumor drugs shows more than 25 agents currently in Phase I or II (3). This and other recent reviews are important reminders of the critical role of natural products as a resource for the discovery of new anti-tumor agents (4,5). The natural product artemisinin (1) is a sesquiterpene endoperoxide first isolated in 1971 from the Chinese plant Artemisia annua (6). The compounds as numbered herein are depicted in FIG. 1. The compound was shown to have anti-malarial activity against both chloroquine-sensitive and chloroquine-resistant strains of Plasmodium falciparum. 
Because of the importance of the clinical effects of artemisinin in treating malaria, many derivatives were prepared in order to develop the most effective and least toxic anti-malarial agent. Initially, simple derivatives were prepared—e.g., dihydroartemisinin (DHA, in which the lactone carbonyl is reduced resulting in a hemiacetal), artemether (the methyl ether of DHA) and several other ether and ester analogs. The sodium salt of the hemisuccinate ester (sodium artesunate) was one of these derivatives that showed more activity and less toxicity than artemether, the latter being more active than artemisinin itself. Continued interest in the activity of artemisinin and DHA analogs later resulted in the preparation of artemisinin acetal dimers through reaction of dihydroartemisinin with borontrifluoride-etherate.
In addition to its anti-malarial activity, artemisinin had been reported to have cytotoxic effects against EN-2 tumor cells (7), P-388, A549, HT-29, MCF-7, and KB-tumor cells (8). As more analogs were evaluated for anti-tumor activity, it was reported that the unsymmetrical dimer (2) showed strong cytotoxic activity and was more potent than cisplatin (9). The symmetrical dimer (3) also showed pronounced cytotoxic activity (10).
This finding stimulated interest in other types of DHA dimers. Posner et al. (11) prepared dimers linked with a polyethylene glycol spacer (3 units of ethylene glycol), an eight carbon glycol, and a dithio-derivative. The authors also prepared simpler trioxane dimers. Posner et al. also prepared several dimers of DHA where the linking units between the two molecules of dihydroartemisinin were dicarboxylic acids of different types (12). Zhang and Darbie (13,14) also proposed several dihydroartemisinin dimers to be linked via different coupling agents. Some of these artemisinin dimers and some of the simpler trioxanes had anti-malarial effects, anti-cancer activity, and anti-proliferative effects with some compounds being as active as calcitriol in an anti-proliferative assay in murine keratinocytes.